Professional Documents
Culture Documents
Complete page 2 of this form to tell us what information you want. Photocopy page 2 for
multiple requests.
Yes
Photocopy of Original Application for Social Security Card (SS-5)
If SSN of deceased individual is provided, the fee is $27.00.
If SSN of deceased individual is not provided, the fee is $29.00.
Computer Extract of SS-5 (May not contain the names of the individuals parents and the place
of birth)
If SSN of deceased individual is provided, the fee is $16.00.
If SSN of deceased individual is not provided, the fee is $18.00.
Certified copy is provided for an additional fee of $10.00 (See instructions below)
Complete as much information as possible in Blocks 4 and 5, if the deceased individuals SSN
is unknown.
Certification is usually not necessary unless you plan to use the information in court.
Method of Payment.
Payment can be made with a credit card by completing the attached Form SSA-714 and returning
it with your request(s) form. You may also pay with a check or money order (Name, Address and
Phone Number must appear on Check). Enclose one check or money order for the entire fee
required (total from request(s)). DO NOT SEND CASH.
Page 1
A. $
B. $
C. $
D. $
E. $
Add the amounts from Lines A through E and enter TOTAL on Line F
F. $
Paying with a CREDIT CARD, complete and return Form SSA-714 attached, or Enclose your CHECK or MONEY
ORDER for the amount on line F payable to Social Security Administration. DO NOT SEND CASH. DO NOT SEND
SELF-ADDRESSED STAMPED ENVELOPE.
4. DECEASED INDIVIDUALS INFORMATION (COMPLETE AS MUCH INFORMATION AS POSSIBLE)
Name of Individual at birth (first, middle, last name)
Name(s) of Individual (if other than above/other name(s) used)
Check Sex
M
Date
Street Address
Telephone Number
E-Mail Address
Page 2
Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget (OMB)
control number. We estimate that it will take about 7 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments relating to our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
Page 3